Lisa is a 35-year-old female with underlying diagnosis of fistulizing Crohn’s colitis who underwent total abdominal colectomy (TAC) with end ileostomy. She had a difficult postoperative course complicated by ileus, high ostomy output, and slow introduction to oral diet. A nutrition consult was received for management of high ostomy output and malabsorption. Her ileostomy effluent was described as thin and watery.
Nutrition Assessment
• Anatomy: Patient has entire small bowel to ileostomy and no colon remaining, no ileocecal valve (ICV), no rectum, and no anus. The patient has no further potential for bowel reconnective surgery.
• Oral intake history: Decline in appetite and oral intake over past 3 months due to abdominal pain, nausea, and diarrhea. Before admission she was eating ½ of her usual meals. Unable to tolerate commercial nutrition supplements. Fluids: drinks “lots of fluids” (coffee, iced tea, water) , 8 to 10 glasses per day
• Current intake: taking 50% of meals provided, tolerating snacks, and sipping up to 500 mL of oral rehydration solution (ORS) daily. She feels that her appetite is slowly improving.
• Weight history: Ht: 152.4 cm (60 inches) Wt: 43.2 kg (95 lb), dosing weight BMI: 18.6 kg/m2
• Usual body weight: 51 kg (112 lb); weight change: 15% change 3 3 months (significant weight loss)
• Physical examination: sunken, dark eye sockets, slight depression at temples, scapula protrudes, thin quadriceps and calves, fat loss at the ribs, no edema
• Functional capacity: low energy level over past 3 months, unable to go to her son’s soccer games, fatigued and tired all the time
• Medications: started loperamide 2 mg before meals and bedtime, chewable multivitamin, KCl sustained release tablet, IV fluids to replace stoma losses
• 24 hour urine and ostomy output: 650 ml and 2200 ml
• Pertinent labs: serum sodium (130) low, serum potassium (3.4) low, serum magnesium (2.0) low normal, CRP: not available, stool toxin analysis for Clostridium difficile negative
• Current diet: GI Soft Fiber-controlled diet, Low Simple Sugars Diet
Nutrition Diagnoses (Pes Statement)
• Malnutrition (P) related to chronic illness (E) as evidenced by inadequate energy intake, weight loss, subcutaneous fat loss, muscle loss, and decline in functional capacity (S)
• Suboptimal protein-energy intake (P) related to altered GI function (E) as evidenced by high output stoma and weight loss (7.8 kg loss over 3 months representing 15% weight change 3 3 months) (S)
Nutrition Interventions
• Estimated energy needs: 1300 to 1700 calories/day (30 to 40 kcal/kg/day)
• Estimated protein needs: 65 to 86 g protein/day (1.5 to 2.0 g protein/kg/day)
• Nutrition goal(s): Oral intake to meet estimated needs, and stabilize ostomy output to the point where patient’s hydration is maintained.
• Replace electrolyte and fluid losses. Monitor fluid balance.
• Continue GI soft fiber-controlled, low simple sugars diet. Patient to make high-salt, high-starch, low simple sugar food choices from the menu. Encourage separation of beverages at mealtimes.
• Provide salty/starchy snacks between meals. Encourage “thickening foods,” such as boiled white rice, pasta, noodles, bread, potatoes, banana, oatmeal, applesauce, peanut butter, cheese, and tapioca pudding.
• Sip 1 L of oral rehydration solution (ORS) between meals.
• Avoid caffeinated and hypertonic fluids.
• Consider trial of soluble fiber supplement to slow down transit time and thicken stoma output.
• Continue escalation of antidiarrheal medications depending on volume and consistency of ileostomy effluent.
• Diet education: discuss with patient and family nutrition management of high output stoma and maintaining hydration with ileostomy.
• Monitor ostomy output and assess need for home intravenous fluids (HIVF) versus home parenteral nutrition (HPN).
Nutrition Monitoring And Evaluation
• Monitor oral intake via calorie counts with a goal of meeting 75% to 100% of estimated energy and protein needs.
• Monitor ostomy output via intake/output records (I/Os) and stabilize to less than 1500 ml per day before hospital discharge.